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GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF THE INSPECTOR GENERAL

OIG 04-2-06RM April 12, 2005

AUDIT OF THE DEPARTMENT OF MENTAL HEALTH’S COMPLIANCE

WITH PERIODIC PSYCHIATRIC EXAMINATION REQUIREMENTS

Austin A. Andersen INTERIM INSPECTOR GENERAL

GOVERNMENT OF THE DISTRICT OF COLUMBIA Office of the Inspector General

Inspector General

April 12, 2005 Martha B. Knisley Director Department of Mental Health 64 New York Avenue, N.E., 4th Floor Washington, D.C. 20003 Dear Ms. Knisley: Enclosed is the final audit report summarizing the results of the Office of the Inspector General’s Audit of the Department of Mental Health’s Compliance with Periodic Psychiatric Examination Requirements (OIG 04-2-06RM). The audit was initiated as a result of an internal referral from the Assistant Inspector General for Investigations. We discussed the finding and recommendations in this report during the audit with your representatives in the Department of Mental Health (DMH), who were receptive and took effective corrective actions. We also discussed issues with officials of the Family Court of the Superior Court of the District of Columbia (Court) concerning the Court’s continuing assistance to the Department of Mental Health to provide information useful for DMH’s process for conducting and monitoring periodic psychiatric examinations. The Court provided comments during the audit. See Exhibit B. We appreciate the cooperation and courtesies extended to our staff during the audit. If you have questions, please contact William J. DiVello, Assistant Inspector General for Audits, at (202) 727-8279. Sincerely,

Austin A. Andersen Interim Inspector General Enclosure AAA/ws cc: See Distribution List

717 14th Street, N.W., Washington, D.C. 20005 (202) 727-2540

Martha Knisley, Director, DMH April 12, 2005 OIG No. 04-2-06RM – Final Report Page 2 of 3

DISTRIBUTION: The Honorable Anthony A. Williams, Mayor, District of Columbia (1 copy) Mr. Robert C. Bobb, Deputy Mayor/City Administrator, District of Columbia (1 copy) Ms. Alfreda Davis, Chief of Staff, Office of the Mayor (1 copy) Mr. Gregory M. McCarthy, Deputy Chief of Staff, Policy and Legislative Affairs (1 copy) Mr. Vincent Morris, Director, Office of Communications (1 copy) The Honorable Linda W. Cropp, Chairman, Council of the District of Columbia (1 copy) The Honorable Vincent B. Orange, Sr., Chairman, Committee on Government Operations,

Council of the District of Columbia (1 copy) Mr. Herbert R. Tillery, Deputy Mayor for Operations (1 copy) Mr. Stanley Jackson, Deputy Mayor for Planning and Economic Development (1 copy) Mr. Neil O. Albert, Deputy Mayor for Children, Youth, Families, and Elders (1 copy) Mr. Edward D. Reiskin, Deputy Mayor for Public Safety and Justice (1 copy) Ms. Phyllis Jones, Secretary to the Council (13 copies) Mr. Robert J. Spagnoletti, Attorney General for the District of Columbia (1 copy) Dr. Natwar M. Gandhi, Chief Financial Officer (5 copies) Ms. Deborah K. Nichols, D.C. Auditor (1 copy) Ms. Kelly Valentine, Interim Chief Risk Officer, Office of Risk Management,

Attention: Rosenia D. Bailey (1 copy) Ms. Dianne K. King, Esq., Director, Family Courts, Superior Court of the District of

Columbia Mr. Jeffrey C. Steinhoff, Managing Director, FMA, GAO (1 copy) Ms. Jeanette M. Franzel, Director, FMA, GAO (1 copy) The Honorable Eleanor Holmes Norton, D.C. Delegate, House of Representatives

Attention: Rosaland Parker (1 copy) The Honorable Tom Davis, Chairman, House Committee on Government Reform

Attention: Melissa C. Wojciak (1 copy) Ms. Shalley Kim, Legislative Assistant, House Committee on Government Reform (1 copy) The Honorable Rodney Frelinghuysen, Chairman, House Subcommittee on D.C.

Appropriations (1 copy) Mr. Joel Kaplan, Clerk, House Subcommittee on D.C. Appropriations (1 copy) Mr. Tom Forhan, Staff Assistant, House Committee on Appropriations (1 copy) The Honorable George Voinovich, Chairman, Senate Subcommittee on Oversight of

Government Management, the Federal Workforce, and the District of Columbia (1 copy) Mr. David Cole, Professional Staff Member, Senate Subcommittee on Oversight of

Government Management, the Federal Workforce, and the District of Columbia (1 copy) The Honorable Richard Durbin, Senate Subcommittee on Oversight of Government

Management, the Federal Workforce, and the District of Columbia (1 copy) Ms. Marianne Upton, Staff Director/Chief Counsel, Senate Subcommittee on Oversight of

Government Management, the Federal Workforce, and the District of Columbia (1 copy) The Honorable Sam Brownback, Chairman, Senate Subcommittee on D.C. Appropriations

(1 copy)

Martha Knisley, Director, DMH April 12, 2005 OIG No. 04-2-06RM – Final Report Page 3 of 3

Ms. Mary Dietrich, Appropriations Director, Senator Sam Brownback (1 copy) The Honorable Mary Landrieu, Senate Subcommittee on D.C. Appropriations (1 copy) Ms. Kate Eltrich, Clerk, Senate Subcommittee on D.C. Appropriations (1 copy) The Honorable Susan M. Collins, Chair, Senate Committee on Governmental Affairs

Attention: Johanna Hardy (1 copy) The Honorable Joseph Lieberman, Ranking Minority Member, Senate Committee on

Governmental Affairs, Attention: Patrick J. Hart (1 copy)

OIG No. 04-2-06RM Final Report

AUDIT OF THE DEPARTMENT OF MENTAL HEALTH’S

COMPLIANCE WITH PERIODIC PSYCHIATRIC EXAMINATION REQUIREMENTS

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TABLE OF CONTENTS

PAGE EXECUTIVE DIGEST............................................................................................................1 INTRODUCTION....................................................................................................................3

BACKGROUND ...........................................................................................................3 OBJECTIVE, SCOPE, AND METHODOLOGY .........................................................3

FINDING, RECOMMENDATIONS, AND MANAGEMENT ACTIONS ........................5

FINDING: PERIODIC PSYCHIATRIC EXAMINATIONS.......................................5 EXHIBITS

EXHIBIT A: SUMMARY OF POTENTIAL BENEFITS RESULTING FROM AUDIT.....................................................................................12

EXHIBIT B: CORRESPONDENCE FROM THE FAMILY COURT OF THE

SUPERIOR COURT OF THE DISTRICT OF COLUMBIA .............13

EXHIBIT C: DMH PROGRESS REPORT...............................................................14 EXHIBIT D: MANAGEMENT REPRESENTATIVE LETTER .............................17 EXHIBIT E: PERIODIC EXAMINATION COMPLIANCE REPORT ..................19

OIG 04-2-06RM Final Report

EXECUTIVE DIGEST

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OVERVIEW This report summarizes the results of the Office of Inspector General’s (OIG) audit of the Department of Mental Health’s (DMH) efforts to comply with legal and procedural requirements for Periodic Psychiatric/Psychological Examinations (examinations) of civilly committed individuals pursuant to D.C. Code § 21-546 (LEXIS through 2004 legislation). DMH describes these individuals as consumers. The objective of our review was to determine whether the psychiatric examinations were performed every 90 days as required by law. SYNOPSIS DMH did not adequately maintain listings of consumers subject to periodic examinations and did not adequately monitor its mental health providers to insure examinations were conducted. Because of the sensitivity of such examinations and the need to ensure compliance with District law, we briefed DMH about this audit finding, made verbal recommendations for corrective action, and monitored the implementation of our verbal recommendations until such time that we could substantiate that consumers were being examined as intended. During our audit, DMH aggressively addressed our recommendations to ensure mental healthcare providers were complying with statutory requirements relating to civilly committed consumers receiving timely examinations. Further, DMH actions have improved the process to ensure that consumers were examined in accordance with procedural legal requirements. Given these actions, we are issuing this final report which includes our recommendations and DMH’s actions to correct the deficiencies. PERSPECTIVE Management Representative Letter. DMH has taken aggressive action in response to OIG observations. DMH prepared, at the request of the OIG, a Management Representative Letter addressing the factors impacting the District’s public mental health system’s reform and re-design since 2000. The Letter also delineates activities occurring from 2000 to 2004, which affect the examinations. Some of these activities took place during and immedia tely following our field work. For example, in January 2004, DMH produced an information packet for providers to use in implementing examination requirements. In February 2004, DMH completed a comprehensive listing of consumers. Discussion Paper. In May 2004, we presented DMH with a discussion paper that contained detailed information supporting the finding that examinations were not being given in a


EXECUTIVE DIGEST

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timely manner and that the accounting for civilly committed consumers was not accurately documented. This discussion paper allowed DMH the opportunity to present its perspective regarding the circumstances affecting the DMH organization as it related to examinations and to verify actions underway to improve the examination process. We received DMH’s response in June 2004. Progress Report. In September 2004, we asked DMH to provide a progress report with regard to its actions to correct the deficiencies we noted. DMH’s response in October 2004 noted improvements in monitoring and reporting as well as compliance with legal requirements and communications with clinical directors (Exhibit C). DMH also had prepared specifications for an automated examination tracking system to improve the tracking and monitoring of consumers subject to examinations. Systems development was contingent on the availability of funding. We appreciate DMH’s positive reaction upon notification of review results. The comprehensiveness of DMH efforts has already resulted in improved examination compliance levels. We additionally noted the added internal controls and improvements in management visibility in the examination process. We also appreciate the positive attitude and cooperative nature of DMH staff involved in this review and the professionalism and courtesy extended to our audit staff.


INTRODUCTION

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BACKGROUND The Inspector General received a written complaint that the Department of Mental Health was not in compliance with the “Ervin Act.”1 The complaint alleged that DMH was not adhering to the requirement that civilly committed persons must be examined by a psychiatrist or psychologist within 90 days of commitment by court order and every 90 days after the previous examination. It was further alleged that DMH was not in compliance with DMH Policy 303.1, Periodic Psychiatric Examinations, dated July 30, 2002.2 Both the D.C. Code and DMH Policy require mental health providers to schedule and perform examinations (also referred to as the “Streicher Exam”) of involuntarily committed consumers every 90 days from the court order issue date or date when a review period of commitment begins. Involuntarily committed consumers are those who have been civilly committed by a court order. The Assistant Inspector General for Investigations referred these allegations to the Assistant Inspector General for Audits. As a result, the OIG informed the Director, Department of Mental Health of its plans to conduct an audit to determine the extent of compliance with laws and regulations regarding the conduct of mental health examinations. OBJECTIVE, SCOPE, AND METHODOLOGY The objective of our audit was to determine whether civilly committed consumers were receiving periodic mental health examinations as required by law. In order to meet our objective, we reviewed the D.C. Code, as well as DMH policy and procedures. We also interviewed DMH and contractor mental healthcare provider staff. To determine the extent of compliance with laws and regulations addressing periodic psychiatric examinations, we reviewed the medical charts for assigned committed consumers at 3 of the 11 mental healthcare provider facilities. Using documents provided by the Department of Mental Health that listed consumers assigned to contractor outpatient mental health clinics, we selected a sample of clinics to visit. We examined consumer charts at those clinics to determine the frequency of periodic psychiatric examinations required by statute. The time frame of our review was examinations required to be conducted between August 30, 2002, through December 2003.

1 The “Ervin Act” was enacted by Congress in 1965 as the “District of Columbia Hospitalization of the Mentally Ill Act,” Pub. L. No. 88-597, 78 Stat. 944. It has been amended on several occasions since that time and is currently codified at D.C. Code §§ 21-501-21-591 (LEXIS through 2004 legislation). 2 DMH Policy 303.1 was updated on December 15, 2003, through the issuance of DMH Policy 303.1A. DMH Policy re-assigned responsibility for tracking and monitoring periodic psychiatric examinations to the Office of Consumer and Family Affairs.


INTRODUCTION

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We also contacted the Presiding Judge of the Family Court, D.C. Superior Court and the Public Defender Service for the D.C. Mental Health Division to determine whether their records would corroborate the individuals DMH listed as subject to periodic examinations. Because of the significance of the finding, we deviated from the standard procedure of issuing a draft report. We informed DMH of conditions as we became aware of them. Subsequently, we requested a Management Representative Letter. The DMH responded with a representation of DMH’s activities regarding the examinations of civilly committed individuals. We issued a discussion paper that would allow DMH to respond to our informally presented finding and suggest corrective actions. We also presented actions reportedly taken by DMH. DMH’s response was reviewed and documentation was requested to support reported activities as necessary. Our audit was conducted in accordance with generally accepted government auditing standards and included such tests as we considered necessary under the circumstances.


FINDING, RECOMMENDATIONS, AND MANAGEMENT ACTIONS

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FINDING: PERIODIC PSYCHIATRIC EXAMINATIONS

DMH did not ensure that outpatient clinics provided some consumers with periodic psychiatric examinations in accordance with District law. In other cases, consumers did not receive the examinations at the frequency required by law. DMH did not achieve compliance with legal requirements because DMH did not adequately maintain listings of consumers subject to periodic psychiatric examinations and did not adequately monitor its mental healthcare providers to ensure examinations were conducted. DMH partially attributed this condition to the lack of an adequate automated system to track consumers who were civilly committed. The lack of periodic psychiatric examinations could result in consumers’ commitment to outpatient mental health facilities longer than needed and place the District at risk for legal liability. DISCUSSION In order for DMH to be effective in complying with Ervin Act requirements, DMH needs to maintain the integrity of its database of civilly committed consumers; improve communications with its mental healthcare providers; provide oversight to the process; and ensure that DMH managers and executives are periodically apprised of the status of DMH’s compliance with the law. Data Base of Civilly Committed Consumers. Concurrent with our January 2004 visits to selected contract mental healthcare providers, the Director, Office of Consumer and Family Affairs, delivered an information packet to St. Elizabeths Hospital and all DMH certified providers, which contained information to aid clinicians in providing timely and accurate periodic psychiatric examinations. The packet also included a list of civilly committed consumers assigned to each respective clinic/provider and the providers were asked to report all assignment errors. During our clinic visits, we confirmed DMH’s concern that the list of consumers was out-of-date. DMH issued an updated list on March 2, 2004. We compared the updated list with the earlier list and found that 53 consumers were not on the updated March 2 listing. DMH accounted for this variance and, on March 23, 2004, issued another updated listing. We attempted to verify the March 23, 2004, listing with the Family Court. However, the Family Court was unable to provide assistance in validating the list but may be able to do so in the future.



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DMH needs to maintain and control the accuracy of its lists of civilly committed consumers in order to manage and monitor compliance with Ervin Act requirements. Communications with Mental Healthcare Providers. We found that DMH was inconsistent in performing and reporting consumer periodic psychiatric examinations, and that there was inadequate communication between DMH and mental healthcare providers. Subsequent steps taken by DMH should improve the timeliness of mandatory examinations of civilly committed consumers. For example, DMH’s regular attendance at the mental healthcare provider’s monthly meetings and visits to provider sites will assist in DMH’s oversight effort to ensure providers are in compliance with legal requirements. A system facilitating open dialogue between stakeholders promotes early identification of potentially problematic conditions and the opportunity for resolution at minimal cost. Oversight of Mental Health Providers. DMH did not ensure that mental health clinics were in compliance with D.C. Code § 21-546 and DMH Policy No. 303.1, Periodic Psychiatric Examinations. Inadequate oversight prevented DMH from detecting the lack of timely consumer examinations by its mental healthcare providers. To determine the frequency of periodic psychiatric examinations, we reviewed a total of 28 client charts at 3 DMH contractor outpatient clinics. A periodic psychiatric examination is required at least every 90 days and is to be documented using DMH Form 139 (Periodic Psychiatric Examination). However, we found little documentation supporting required periodic examinations. Of the 28 consumer files we examined, we determined that a total of 104 examinations were required. We found documentation supporting a total of 12 examinations for 10 of the 28 consumers and no documentation for the remaining 18 consumers. In conducting our review, we took into consideration the amount of time the consumer was not under the clinic’s control, such as the time spent to St. Elizabeths Hospital, based on available chart data. Early Executive and Management Action. Our review of DMH’s revisions to the periodic psychiatric examination process since we discussed our findings has shown DMH to be responsive. DMH has instituted internal controls and assigned the DMH Streicher Coordinator responsibility for monitoring compliance with consumer examination requirements.



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RECOMMENDATIONS AND MANAGEMENT ACTION Recommendation 1. We recommend that the Director, Department of Mental Health, continue to maintain the integrity of the civilly committed consumer database. Primary and backup responsibilities should be assigned. Duties should address periodic database reconciliation with mental healthcare providers, the St. Elizabeths Hospital registrar, and the committing court.

Management Action. DMH’s Grievance and Streicher Program Specialist (Streicher Coordinator) is responsible for updating the database of civilly committed patients. In March 2004, the DMH Director reported to the Interim Inspector General (Exhibit D) that in February 2004 DMH finalized “the most complete and accurate listing to date . . . .” The Coordinator, using the updated database, devised a reporting process, whereby each mental healthcare provider receives an individualized monthly report. This report, entitled “Committed Patient’s Psychiatric Examination Review,” provides patient data relating to scheduling and conducting exams. The report provides the exam due date, actual exam date, and next exam due date. This report is used as an aid in assuring the exams are given in a timely manner. The Office of Consumer and Family Affairs has provided cross-training to two of its employees on the tracking duties of the Coordinator, thus providing continuity of operations in the event of the unavailability of the primary person. DMH is continuing its efforts to automate the tracking of consumers and their examination status. Due to fiscal constraints, however, DMH was unable to carry through with its plans for development of a new management information system. DMH had an agreement with the Mental Retardation and Development Disabilities Administration (MRDDA) to modify an existing MRDDA application to satisfy DMH’s needs, and developed specifications that were delivered to MRDDA in late fiscal year 2004. Start up is contingent upon fund availability. In the interim, the Coordinator continues using a spreadsheet to track committed consumers and for reporting purposes.

OIG Comments. DMH staff has been responsive to the OIG’s concerns with regard to an accurate database. We strongly encourage independent reviews, especially by the committing court, of the individuals listed as subject to periodic examinations. DMH has provided for continuity of operations in the event the primary person responsible (the Coordinator) is unavailable by having staff cross-trained in the functions of the Coordinator. Recommendation 2. We recommend that the Director, Department of Mental Health, amend current policies and procedures to include monitoring and oversight activities. These procedures should address oversight aspects, which would ensure the integrity of the process, timeliness of examinations, and compliance with laws and regulations governing psychiatric



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examinations. Such policies and procedures should also consider occasional unscheduled visits to mental healthcare providers.

Management Action. DMH assigned to the DMH Streicher Coordinator the responsibility for monitoring the status and accuracy of consumer examinations. The Coordinator has provided technical assistance to providers during site visits and participated in meetings.

• Compliance Monitoring. DMH reported improvement in compliance with examination timeliness requirements. In July 2004, DMH determined the highest reported compliance rate for its providers to be 82 percent. In October 2004, 7 of 11 providers had 100 percent compliance levels (Exhibit E). DMH is currently in the process of developing “reasonable and fair” requirements considering factors affecting compliance, such as the transient nature of clients. The monthly progress reports contain detailed data supporting the compliance percentages as calculated by the Coordinator. Providers may challenge the accuracy of these percentages. Thus far, we understand, they have not. The Coordinator’s process is subject to review by the DMH Internal Auditor, thus providing another level of integrity in reporting.

DMH also reported that the DMH Internal Auditor conducts audits of the provider agencies. These audits review statistically sampled medical records on a quarterly and annual basis. Deficiencies are noted and the provider is required to prepare a corrective action plan.

• Sanctions for Non-Compliance. In October 2004, we were informed that the DMH

Office of Accountability, with assistance from the DMH Internal Auditor and the DMH General Counsel, were in the process of finalizing an Enforcement Action Procedure (EAP) (Exhibit C). The EAP will be used to enforce the D.C. Civil Infraction Act of 1985 and Title 16 DCMR Chapter 32. Non-compliance with consumer examination timeliness requirements is punishable by a $500 fine per civilly committed patient. Upon finalization of the EAP, DMH will provide training to the providers on the procedure. Clinical directors have been notified that future infractions will subject them to a fine.

• Internal Controls. A review of the DMH’s “546 Tracking Process” flow chart

indicated the inclusion of considerable internal controls over the examination process. We found direct Coordinator involvement in most actions. This involvement includes: (1) a weekly query of the consumer database to determine those clients that are due for examination; (2) the creation and distribution of exam notifications; (3) receipt of notice of examination completion, and (4) updating the database. For steps not directly performed by the Coordinator, documentation indicating whether an



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examination was completed and a copy of the attending psychiatrist’s written exam results are required to be sent to the Coordinator.

• Provider Agreement Revised. The Human Care Agreement, which DMH requires

all of its providers to sign, has been revised. The revisions include:

• 2.1 All providers certified by DMH, as core service agencies, shall abide by the requirements of the District’s Hospitalization of the Mentally Ill Act, commonly referred to as the Ervin Act. D.C. Official Code §§ 21-501 et. seq. Provider, as applicable, agrees:

• 2.1.1 To notify DMH when a consumer with a voluntary legal

status requests his or her discharge from treatment, consistent with D.C. Official Code § 21-512;

• 2.1.2 To ensure that consumers who are court committed,

pursuant to D.C. Official Code § 21-545 or § 21-545.01, to DMH (or its predecessor agency, Commission on Mental Health Services), receive timely review of their commitment status as required by D.C. Official Code § 21-546 and that copies of the commitment review reports are submitted to DMH as required by DMH policy, rules or regulations; and

• 2.1.3 To ensure that the requirements of the Ervin Act regarding

transfer of consumers receiving outpatient or community based services who are court committed, pursuant to D.C. Official Code § 21-545 or § 21-545.01, to DMH (or its predecessor agency, Commission on Mental Health Services), to inpatient or hospital based services, including but not limited to preparation and submission of the required notification to the court within 24 hours of the transfer from outpatient treatment to inpatient treatment, as required by D.C. Official Code § 21-548 and related court and DMH policies, rules or regulations.

OIG Comments. DMH has taken action to assure psychiatric consumer

examinations are administered within time constraints by developing and instituting internal controls. These controls provide for the monitoring of the process by a DMH staff person. This staffer also maintains the patient database, issues monthly status reports to providers, and attends monthly provider meetings. This process can only serve to preserve the integrity of the exam process and contribute to statutory compliance. The added action of informing providers of the intent to enforce testing requirements by



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imposing fines for violations further strengthens DMH’s resolve to ensure compliance with the provision of the Ervin Act and DMH regulations. Recommendation 3. The Director, Department of Mental Health, needs to provide a representative at the monthly clinical directors meetings and provide necessary guidance.

Management Action. DMH, in their Management Representation Letter, informed the Interim Inspector General that beginning in March 2004, the Office of Consumer and Family Affairs (OCFA) would be represented in the monthly meetings of providers’ Clinical Directors (Exhibit D). We reviewed the minutes from the monthly meetings held from March through August 2004. During this period, of the 6 meetings held, the designated Streicher Coordinator was present for all but one of them. During these meetings, the DMH representative distributed monthly Streicher Examination compliance reports, provided guidance regarding compliance, and made the attendees aware of the OIG’s involvement with compliance issues. DMH’s October 2004 progress report to the OIG (Exhibit C) declared that, effective in November 2004, the DMH Director ordered consumer examination compliance reporting to be added to the agenda of the monthly Provider Chief Executive Officer (CEO) meetings. Written compliance status letters will be presented to each CEO during the meetings. CEO’s will then be required to submit to DMH a corrective action plan. Non-performance of the corrective action plan will subject providers to civil infraction fines. The DMH Office of Accountability has responsibility for monitoring and reporting on compliance with corrective action plans. Compliance reports will be made public, and CEOs will receive a monthly report on the status of compliance.

OIG Comments. DMH’s actions to involve each provider’s top management in the examination process provides the necessary notice that the statutory and regulatory requirements regarding the administration and reporting of periodic psychiatric examinations will be complied with, and noncompliance will result in sanctions. DMH is to be commended in taking this aggressive position. Recommendation 4. The Director, Department of Mental Health, needs to establish a process by which the Director receives timely notice of problems which might cause DMH to be noncompliant with the law with regard to consumer examinations.

Management Action. We were provided with the October 2004 Periodic Psychiatric Examination Compliance Report (Exhibit E) addressed to the Director, OCFA. The Streicher and Grievance Program Specialist has prepared this monthly report since May 2004. The compliance report is also provided to the DMH Internal Auditor. This report presents the compliance rates for the previous month for the mental health providers



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and for St. Elizabeths Hospital. A copy of this report is also provided to the Office of Certification, which notifies providers who are not in compliance with D.C. Code § 21-546 and DMH Policy 303.1.

OIG Comments. It is our understanding that the Director, DMH, also receives the monthly compliance reports prior to their distribution at the monthly Provider CEO meeting. This will allow the Director the opportunity to provide input at the meetings. Prior to November, the DMH Internal Auditor briefed the Director on the report’s findings on an ad hoc basis. DMH’s actions are satisfactory and meet the intent of our recommendation.


EXHIBIT A: SUMMARY OF POTENTIAL BENEFITS RESULTING FROM AUDIT

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Recommendation Description of Benefit Amount and

Type of Benefit

Status 3

1 Compliance and Internal Control. Continue to maintain civilly committed consumer database.

Non-monetary Closed

2 Compliance and Internal Control. Amend policies and procedures to include monitoring and oversight.

Non-monetary Closed

3 Compliance and Internal Control. Continue to attend the Clinical Director’s monthly meetings.

Non-monetary Closed

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Compliance and Internal Control. Establish a process assuring the DMH Director’s timely notice of potential non-compliance with statutory examination requirements.

Non-monetary Closed

3 This column provides the status of a recommendation as of the report date. For final reports, “Open” means Management and the OIG are in agreement on the action to be taken, but action is not complete. “Closed” means management has advised that the action necessary to correct the condition is complete. “Unresolved” means that management has neither agreed to take the recommended action nor proposed satisfactory alternative actions to correct the condition.

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